MEDICARE: DR. CAROLYN BLAIR BURNETTE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	6301019260	MI

General Provider Information

NPI Number	:	1922709559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROLYN BLAIR BURNETTE PHD

Provider Business Mailing Address
First Line	:	411 WEST ST
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48915-1127
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 WEST ST
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48915-1127
Country	:	US
Telephone Number	:	615-308-4769
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2023
Last Update Date	:	03/26/2024

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